STATE OF INDIANA) )§: INTHE DELAWARE CIRCUIT COURT NO. __ DELAWARE COUNTY) Petitioner And CAUSE NO._ Respondent WAIVER . Tepresent the Petitioner/Respondent, . in the above captioned cause of action. 1 understand that he/she has been invited to participate in a facilitation process to be held onthe __day of have advised him/her of his/her rights and of the fact that the Facilitation is an effort to reach a resolution. He/She has decided due to the cost faetor, that he/she will participate alone, My client is aware of the phone number where I can be reached for consultation if so desired during the course of the Facilitation. He/She has hereby been given the authority to settle or reach a compromise without my presence being required or my signature on the agreement. Date ‘Attorney for Petitioner/Respondent Date